Ashish V. Shah

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First came the rise of telehealth. Now home-based care is gaining traction with health systems and accountable care organizations (ACOs) as care delivery continues to move outside of the hospital and into the home and community.

 from The Institute of Accountable Care (IAC), showing an increase in home-based care among ACOs. In fact, half of the home-based care programs developed by ACOs were formed between 2017 and 2019 , almost double the 26% formed between 2014 and 2016, according to the same study.

,  recently acquired leading home health companies to solidify their commitment tohome-based solutions that improve patient outcomes and deliver value.

Add in growing consumer demand,and you have a healthcare environment more willing than ever to modify authorization rules and health plan design to enable a shift to in-home care.

Today’s health systems and ACOs need to position themselves for success in this changing landscape. 

But where they start? Here are four strategies to help navigate the shift to home-based care.

Most health systems and ACOs perform some level of tracking, monitoring, and trending into post-acute care 

PAC) facility utilization. But one way visibility is not enough. To optimize care, you need to know not only when patients have moved to a post-acute facility, but what’s happening once they are there.

The first step is to establish a preferred network of post-acute providers and embed those partners in the care planning process. Once you develop a shared set of expectations, care teams can work together to recognize and addresschanges in patient conditions that can reduce emergency department visits and prevent hospital admissions and readmissions.

Electronic, real-time communication and coordination help facilitate proactive care planning. A bidirectional exchange of information can help providers evaluate projected length of stay and identify candidates who can safely be cared for in the home setting. Collectively, these efforts can optimize patient satisfaction and outcomes while reducing costs.

Build a preferred home-based provider network

An effective care-at-home strategy also requires building new partnerships with service providers, including durable medical equipment (DME) suppliers, transportation, meal delivery, courier services, and more. Identifying and establishing connectivity with these services can be challenging. Many home-based providers aren’t licensed or rated by CMS and aren’t owned or operated by large healthcare organizations. Cloud-based technologies can be helpful to evaluate these new types of partners, including assessing their suites of capabilities, service areas, capacity and turnaround time. Working with organizations that can engage with you in a digital manner will be critical.

Drive timely interventions with direct patient connections

Many health Systems and ACOs leverage a variety of remote patient monitoring (RPM) tools to connect directly to patients and proactively track their health status. Unfortunately, these tools are often used only to monitor people with chronic conditions who represent a small segment of the overall need.

Moreover, the data captured by these devices only tells part of the patient story. While these tools may, for example, relay a patient’s A1C reading, they don’t tell the provider if there is healthy food in the refrigerator or if they can prepare themselves a meal.

Truly effective remote engagement needs to combine vital sign data with an engaged care team and  the patients themselves to understand the conditions that may impact someone’s health.

The goal is to help people become active participants in their own care to maintain wellnes, not just when they are recovering from an illness. Participation is most successful when it is easy for the patient. For example, automated check-ins via widely accessible mobile technologies are easier to access than hospital portals that require patients to log in and initiate the interaction.

Healthcare organizations across the country are struggling with staff shortages and burnout. To effectively navigate the shift to home-based care, health systems and ACOs need to find ways to extend their reach into the home without causing staff to feel overburdened or pushed beyond capacity.

Technology is one way to make an impact. We expect to see more providers establish “care traffic control” centers to remotely monitor people at scale and use home-based insights to identify risks and inform care plans. Text-based patient check-ins, for example, are one way to receive feedback in real time and manage by exception to help people stay home safely.

During the height of the Covid-19 pandemic, one of our clients, Jefferson Health in Philadelphia, found that 75% of its Covid-19-positive patients responded to automated, text-based check-ins and remained engaged throughout their recovery at home. Only 3% to 7% of respondents required escalation, and they were evaluated by a care coordinator to determine next steps. This approach allowed care teams to focus their attention on those patients who needed their support the most and intervene if conditions escalated.

By leveraging technology to enhance connectivity and visibility, providers can make care adjustments midstream,  incorporating home-based care where appropriate, and ultimately ensure more successful patient outcomes.

, a Chicago-based care coordination company that focuses on remote and home-based care. 

Articles

One trend to keep an eye on is the establishment of  “care traffic control” centers to remotely monitor patients and use home-based insights to identify risks and inform care plans. 

Ashish V. Shah

Articles

Navigating the Shift to Home-Based Care: 4 Strategies for Success | Ashish V. Shah